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. 0911-ba3t)(\ <br /> Application for Onsite <br /> tor City tlie.Otityx . unte.stamiu <br /> .---.• --3.-,4-,-7i-.;>1-2.4 Wastewater Treatment System 'cilY 6f <br /> 11111111 . <br /> MARION COUNTY PUBLIC WORKS Date Reedited <br /> Received 1?y. „. RECEIVED <br /> BUILDINGINSPKCTION DIVISION Zoning.by MAR 2 2024 <br /> 5155 Sihierton WINE Fee <br /> Salem.OR 97305 <br /> (503)588-5147 Fax.003)588-7948 [ Receipt# .. <br /> ' Activity: * <br /> www.co.mariomorais/PW/BuildinnInsnection i - --'--. . . <br /> , . A.PrupeKty()wner Inforination , <br /> ikAi.4A' - %- <br /> LaLt INAU A:Y t w6,--t Id15-1. (Vot 16 tiz: Nik. if rcr. 011_. 61.10072- 603--7,•tit..,..61-i.)61 <br /> I <br /> Name Mailing Address . City,State,and Zip- (Area Code)Phone# <br /> :.. <br /> . . , T.C.,LotteRtopOty-PerkiOtionr <br /> . . .... <br /> Legal Description. TmcLot Acreage or Lot Size <br /> Subdivision Name Lop Block <br /> 17.1 6e- 12:..6 li...%• v.kAo‘ 0 r <br /> oo — <br /> :,„0 ,,,A0,..„,s City State Zip Code <br /> Directions to Property: <br /> ...,, . - .,,,, C.Existing FaCiliiyOroposed Facility/Water infoximatiou <br /> Existing FaCility; Proposed Fealty: Water Somilyi <br /> Dsingle Family Residence 1531 Single Family Residence DPublie <br /> Numner of liedrooms. *Number:of:Bedrooms . lig Private \j,eA 1 <br /> 1:3: Other 0 Other Well;8pting:.Shared. <br /> 13::Typo ofAlicatiort <br /> '1::j Site Evaluation 0 Renewal Permit .[DAtithorization Notice for: <br /> kri Construction Permit. 0 Permit Reinstatement. 0 Replacing.a Dwelling <br /> 0'Repair Permit 0 Permit Transfer 0 The Addition of One or'Mare Bedroom* • <br /> 0 Major D: Minor .0 Ekitirig Sy$tetn Evaluation .0 Personal Hardahip. <br /> 0:1 Alteration Permit 0,Record Review 0 Temporary Housing. <br /> 0 Major 0 Minor 0. Other 0 Connecting to an Existing System Never in Use <br /> (O•lret:5,yrs old) <br /> El Othe-Please 8peeify <br /> lithe required*.gm)attachments4re not'incanied with this application,it will he rettimetiltayou as incomplete. <br /> Potithetnange:card at the entrance to the property. Flag the test holes. <br /> By My signature,I certify that the information I have furnished is correct,and hereby grant Marion CtiOnty4.aotboriect agent at the. <br /> Department of Environmental Quality,,perr_nission to,enter onto the above described property for the sole'purpose of this application. <br /> CC <br /> . 3c.13 <br /> Applcori!sNme-Please P1at Legibly Applicant's Phone Number DEQ.Lic."4. (if applicable) <br /> 91-7-1 bi\. 0:10 09-.-- q-730S. <br /> Applicant's Mailing Mdrest. <br /> Si <br /> 41(1)94. <br /> attire Date: CCB# (if applicable). <br /> AppliCant is the 0 OVitier Autlioriged Representative .0 Authorization to Apply form Attached <br />